By Greg Price
The Taber Clinic is still basking in the after glow of a Health Quality Council of Alberta (HQCA) study with years of research that has shown evidence of the value, cost, and quality of care delivered in the clinic’s unique alternate-funding model, which had been implemented since 2001.
Alternate funding models are designed so that health care providers are paid a prospective amount to cover services provided to patients within a specific period of time, versus a fee-for-service model more typical in Alberta primary care clinics.
“Most of the province, whether you are in a rural or urban environment, when you see your physician, that physician is on a fee-per-service model. You get paid per units of work. You get paid for a prescription, or a lab result, and some places you go, physicians don’t have the support of a team around them,” said Andrew Neuner, chief executive officer of HQCA. “When you come to the Taber Clinic, the first thing you see is all sorts of folks working there. They are all working together and they all know their patients well because they have nurses, nurse practitioners, and they are having discussions about your care to make sure the most appropriate person is there to support you in any type of care that you need.”
Even though the Taber Clinic has a long history in its alternate-funding model, to the layperson, it is often misunderstood in its delivery parametres.
“Health care is publicly funded in our great country for the most part. Classically, health care for primary care specifically is funded to doctors and the way it is delivered is in our private clinics,” said Dr. Andrea Hargrove of the Taber Clinic. “The way Taber works is we are provided funding from the government for all the patients that we care for, for how much they would cost the government in one year. We are provided that up front and it is not tied to the rules of how most primary care works, which is the private offices and physicians are only paid each time they see a patient, tied to seeing each other in the same room.”
The Taber Clinic receives the funding and are obligated to provide the care the patients need, but are not tied to the seeing each other rule.
“We are able to do it in more creative ways that maximize the access for our patients, because we employ a huge team of people to help us do it. In our clinic, we hire 44-plus staff to help us deliver primary care,” said Dr. Hargrove. “We have patients seen by the most appropriate care provider. Sometimes that’s a nurse, sometimes it’s a counselor, often times it’s your doctor or a doctor that is available for you in the time frame that you need. We have a large enough group of physicians that we do each have special areas of interest or special skills to provide care in the clinic or the hospital. We do facilitate a lot of things so people don’t have to travel as much as they do in other communities.”
The model breaks the mold that all primary care should be delivered by all doctors.
“That isn’t all that efficient, and results in really high wait times. If you go to different communities where they are tied to fee-for-service, it may be three weeks until you can get an appointment. But in our model, we may offer you the nurse practitioner the same day or your doctor later in the week because we aren’t tied to those same rules in order for our businesses to make money,” said Dr. Hargrove. “We pride ourselves in that everyone in our team is working to their full scope of practice to provide the best and most timely care for our patients.”
The HQCA study found the alternate-funding model used by Taber Clinic enabled the design and delivery of a team-based practice model that provided comprehensive, cost-effective care that provides downstream cost-savings to the health system. In 2016-17, the practice models delivered by Taber Clinic realized health system cost savings of $7.2 million. This trend of health system cost savings has been consistent since 2007-08 with 10-year accumulated savings of $62.2 million.
“Everybody kind of knows who you are and they are aware of your history and your med history. Because of that, you are not duplicating things. If by chance, if you need to be admitted to the hospital, because there is the relationship there and they understand you and your health needs, chances are, you will be admitted 30 per cent less often to a hospital. And when you are there, you stay for a shorter amount of time because they have that in-depth knowledge of you,” said Neuner.
Another clinic in the Crowfoot Village Family Practice which adhered to the same model had an accumulated savings of $57.3 million over 10 years while delivering favourable outcomes.
For Dr. Hargrove, it’s a complicated answer to give of why clinics across Alberta have not adopted a similar model to Taber’s given the favourable results of the intensive study done by the Health Quality Council of Alberta.
“It is my understanding that this is the first really good study to prove that what we do is effective and economical. It’s taken 15 years to do this study, and I would hope in seeing this study, the government will offer ARPs (Alternate Relationship Plans) that are more like Taber’s and Crowfoot’s. Rather than trying to re-invent the wheel in offering an ARP that is thus unproven. (With the study) it’s around 35,000 patients over the last 10 years the study was reporting on.”
HQCA’s recommendation from the study is that no new funding agreements should be implemented without first developing a provincial alternate funding model framework that describes the key elements required to support the development and implementation of alternate funding agreements. The framework must be in alignment with, and support the vision for, primary and community care, and be inclusive of the role of Primary Care Networks.
“The government has not been offering more ARPs that are like ours. We’ve spoken with Alberta Health why isn’t it being extrapolated? Especially after the study shows it results in huge savings for the government down the line,” said Dr. Hargrove. “Not savings at the primary care clinic level, but it saves money on emergency room visits, special referrals and hospital admissions. That means our patients are staying out of hospitals, they are healthier because they are getting timely care in the community.”
She added Alberta Health has noted they are limited by their data system in being able to offer more models for clinics to join. In the last few years, they have offered one ARP model.
“That model is not what ours is. It has some limitations and stipulations where people have been pretty reluctant to sign up for. It’s called blended capitation which is the one the government is currently accepting bids for clinics to join. They haven’t had a lot of uptake,” said Dr. Hargrove. “I hope that we can see some change and some pivot from what the political rhetoric has been that primary care needs to be cut. This shows that we need to keep current funding and bolster primary care.”
With the Taber Clinic being a team-based clinic, Dr. Hargrove admitted some patients have expressed dissatisfaction that they don’t see their assigned doctor enough.
“But our team-based model is to give them the most timely service with the most appropriate provider. That doesn’t always mean seeing your doctor. Historically, that has been what’s been expected based on the funding model. But, that’s not to say that’s the best care, the most timely care, and the most effective care,” said Dr. Hargrove. “In models where it is tied to a visit, you are seeing people needing to come back for refills every three months. In our model, we do a lot of refills over the phone or nurses call out for appointments for lab work or follow-up tests. It does save people the inconvenience of having to come to the clinic for a visit if it’s not necessary.”
The Health Quality Council of Alberta also saw in its study a history of employees that have stayed at the Taber Clinic for a prolonged amount of time, showcasing a ripple effect of the alternate-funding model, making for happier employees.